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Based in record review and interviews with facility staff, the hospital does not ensure that all practitioners are working within their scope of privileges while providing patient care. One of one (Staff A) physician assistant working in the emergency room, and whose credential file was reviewed, did not have current privileges granted for the tasks performed. The physician assistant terminated advanced cardiac life support measures and pronounced patient's dead without consultation with a supervising physician (Pt's 1,2,3,4).

Findings:

1. On 2/15/2011 surveyors were provided copies of Medical Staff Bylaws, rules and regulations. Section 3.4-2 stipulates: "Physician assistants are responsible to their supervising physician who remains ultimately responsible for the patient's care. It is the responsibility of the PA-C to discuss their findings with the attending physician upon completion of their examinations. Part 11-Hospital Deaths and Autopsies 11.1 Death Pronouncement: Only the physician may pronounce death in situations of brain death prior to removal of artifical respiratory or circulatory support." Five of five patient records (Pt's 1,2,3,4,5) reviewed did not contain documentation the physician assistant Staff A consulted with a supervising physician prior to termination of advanced cardiac life support measures, prior to transferring patients, or prior to pronouncing a patient dead.

2. On 2/15/2011 surveyors reviewed privileges for a physician assistant, Staff A. Staff A did not have privileges to pronounce patient's dead.

3. On 2/15/2011 surveyors reviewed Medical Staff Meeting Minutes 2010-2011 and Quality Improvement Committee Meeting Minutes 2010-2011. There was no documentation the Medical Staff reviewed or evaluated care provided by the physician assistants. This finding was confirmed with Staff B in an interview the afternoon of 2/15/11. This finding was reviewed with administration on 2/15/11. No further documentation was provided.

Based on review of emergency room (ER) policies and procedures manual, hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure medical staff developed, revised, and enforced the ER policies governing medical care provided in the ER. The physician assistant (PA) provided medical care to ER patients without direction or input from the supervising physician. This occurred in five of five (Records 1,2,3,4,5) of ER medical records reviewed in which Staff A provided care.

Findings:

1. On the morning of 2/15/2011 surveyors were provided the medical staff bylaws, rules and regulations, "section 11 Hospital Deaths and autopsies 11.1 Death pronouncement. Only the physician may pronounce death in situations of brain death prior to removal of artificial respiratory or circulatory support". In five of five medical records (#1,2,3,4,5) in which patient's arrived to the emergency room in cardiac or respiratory arrest with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) measures being performed, Staff A pronounced the patient's dead without documentation of consultation with a supervising physician. Credentialing files for Staff A did not indicate Staff A was privileged to perform this duty.

2. On the morning of 2/15/2011 surveyors were provided copies of the emergency room policy "Emergency Room Subject: Code Blue" The policy stipulates "Emergency room personnel will perform cardio pulmonary resuscitation according to ACLS guidelines. Responsible Party: A. RN, LPN, MD: 1. Place on monitor. 2. Initiate appropriate drug therapy for appropriate heart rhythm. See algorhythms (sic) and drug protocols. 3. Defibrillate as per procedure. 4. Arterial blood gases as soon as possible when indicated. According to the American Heart Association 2010 American Heart Association Guidelines for cardiopulmonary resuscitation-Adult Cardiac Arrest algorithm "Asystole/PEA, cardiopulmonary resuscitation is performed for 2 minutes followed by a rhythm check. If the cardiac rhythm is asystole/PEA, asystole is best determined in 2 separate cardiac leads. CPR is continued and treat reversible causes. Reversible causes to be considered are: hypovolemia, hypoxia, acidosis, hypo/hyperkalemia, hypothermia, tension pneumothorax, cardiac tamponade, toxins, pulmonary or coronary thrombosis. If the cardiac rhythm is ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT) monophasic defibrillation should be attempted at 360 joules."

On the morning of 2/15/2011, Staff C told surveyors defibrillators at the hospital were monophasic. Staff C also told surveyors when pads are used the cardiac monitor lead initially reads in Lead II. Staff C told surveyors emergency personnel would have to change lead settings to have the pads read alternative leads.

On the afternoon of 02/15/2011, Staff B told surveyors the hospital did not have the equipment to run arterial blood gases. Staff B told surveyors asystole should be verified by two or three different cardiac monitor leads. Staff B also stated typically patients would have anterior posterior pads placed along with three cardiac leads. The hospital ' s ER policies and procedures did not contain a policy that provided this direction. Nine of nine medical records reviewed of patients pronounced dead did not contain evidence that asystole was verified by at least two different leads. Staff B told the surveyors that if a patient was in PEA (pulseless electrical activity), documentation should show a Doppler reading had occurred. The ER policy manual did not contain a policy or protocol directing this should occur. ER policies and procedures did not specify who could pronounce patient death.

3. Record #1- The patient presented to the ER at 1946 on 9/29/2010 in cardiac arrest, intubated, with intravenous fluids infusing and ambulance personnel performing CPR. Staff A documented in the "emergency medical physician assessment and progress record -chief complaint as "cardiac arrest" and in the section "exam abnormalities" documented non responsive, skin cool, color dusky on arrival, eyes fixed, pupils~2 mm equal unresponsive, good air entry with assistant ventilator, v-fib (ventricular fibrillation) on arrival, epi (epinephrine) x (times) 3, Atropine x (times) 2, Shock x (times) _____ (section was blank). Staff A documented "pronounced deceased at 2001". Staff A documented "this patient was pronounced dead at 2001 found spontaneous resp, HR (heart rate) pink color 2120 Oxygen sat (saturation) to 99 with ET (endotracheal) tube, skin warm, pedal pulse 2/4, R = L (right equal left), radial pulse 2/4 R= L cheyne stoke resp (respiration)." Further documentation by Staff A indicated in the diagnosis and treatment plan section of emergency room form "MI-resp assist" and "found 2120 with spontaneous resp, heart rate, color pink cheyne stoke resp, oxygen saturation 75-95 with oxygen". Staff A did not document there had been an assessment of the patient prior to life support measures being removed. Staff A did not document consultation with the supervising physician prior to removal of life support, pronouncement of death, or when treatment was resumed after patient was found breathing and with pulses.

Nursing documentation stipulated the patient was defibrillated at 1954 with 120 joules, 1956 with 150 joules, 1958 with 200 joules, and 1959 with 200 joules. Epinephrine administration times were documented by Staff E as 1951, 1955, and 1959. Atropine was documented by Staff E as given at 1952 and 1957. Cardiac rhythm strips were documented by Staff E prior to first defibrillation as "v-fib" (ventricular fibrillation) and after "fourth shock and monitor rechecked, pt in PEA (pulseless electrical activity)". Staff E documented 2001"code called at 2001 by PA. patient with no respirations, no palpital (sic) pulse, no heartbeat heard, no respirations heard by ausculation." Documentation in the chart did not indicate the patient had been checked by doppler for pulses. Staff E documented pt moved to room 101 to await ME (medical examiner). Staff E documented at 2120 "nurse takes wife to rm (room) to view pt (patient) before leaving. Resp. (respirations) heard at door x (times) 3. Wife taken back to waiting rm. Assistance called to rm. Pt with spontaneous resp. O2 (Oxygen) saturations 76%, radial pulses bilateral at 85. Cardiac monitor reapplied with afib (atrial fibrillation) noted. EKG (electrocardiogram) completed. Staff A ventilating patient with increase in oxygen saturation to 98%". The patient was transferred to another hospital at 2242.

4. Record #2 - The patient presented to the ER 12/3/10 at 1800 in cardiac arrest, intubated, with CPR in progress by ambulance personnel. Staff A documented in the emergency medical physician assessment progress record at 1800 chief complaint "cardiac arrest/code blue". In the pain assessment portion Staff A documented "35 y/o (year old) female arrest at home - Checotah EMS". In the portion stipulated exam abnormalities Staff A documented "see note". Staff A documented under the "medications ordered" section- "exam/note (circled) 1800 intubated #9 tube taped at 19 cm BS (breath sounds) equal. No spontaneous resp/no heart rate skin cool mottled asystole intubated 1822 Oxygen saturation 0, HR (heart rate) 0, resp (respiration), expired 1824". Further documentation by Staff A stipulates in the diagnosis section "cardiac/resp arrest. There is no documentation by Staff A there was a consultation with the supervising physician prior to removal of life support. There was no documentation throughout the record indicating the cardiac rhythm asystole was checked in two leads.

Nursing documentation by Staff H indicated "chief complaint as "arrived x (times) with EMS code blue CPR in progress. There was no nursing assessment documented. Staff H documented in the "code blue cardiopulmonary report - epi 1 amp (epinephrine) was given at 1812, 1815, and 1818. Atropine 1 amp was given at 1812. Staff H also indicated the patient was placed on the monitor at 1810 and expired at 1824. Staff H documented CPR was started at 1722 per ambulance personnel. Documentation on the ambulance run sheet indicated CPR was initiated at 1740. Cardiac rhythm strips indicate the monitor was tracing through "pads" setting. No other lead was documented.

5. Record #3 - The patient presented to the ER 1/6/11 at 1540 in cardiac arrest, intubated, CPR and ACLS in progress. Staff A documented in emergency medical physician assessment progress record at 1540, patient arrived in full arrest, thready pulse, no spontaneous respirations. Staff A documented the patient was "unresponsive/see nurses notes, pupils unresponsive, no spontaneous respirations, no pulse or very weak, abdomen distended/ no BS (bowel sounds), pt mottled/cyanotic on arrival, unresponsive, skin cool, unresponsive. Staff A circled "alert, stable, oriented, judgement, and checked no cyanosis, lips/gums no lesions" the physical exam portion. Staff A documented "patient arrive in full code x 30 minutes- no response time of death 1559". At 1600 nursing documentation stipulates a pulse was felt by staff. There is no documentation by Staff A there was a consultation with the supervising physician prior to removal of life support.

On the code blue recording sheet, Staff H documented "time of code blue team arrival as 1540 and time code called as 1559. At 1547 defibrillation was documented at 200 joules and the cardiac rhythm documented by Staff H was course v-fib (ventricular fibrillation). At the bottom of the code sheet was " asystole verified in 3 leads: Y N". Y was circled. No cardiac monitor strips were posted in any lead other than "pads". Staff H documented "1600 (name withheld) feels a pulse." The next entry is at 1605 "no pulse, no respirations code called. There was no documentation in the patient record indicating any further treatment was provided after 1600. Staff A did not document this event and there was no consultation with the supervising physician regarding this event.

6. Record #4 - The patient presented to the ER 1/27/11 at 2005 in cardiac arrest, Combi-tube in place, CPR in progress. Staff A documented in the emergency medical physician assessment progress record at 2005 chief complaint: Code Blue Checotah EMS. Staff A documented the patient was non responsive, pupils fixed, dilated, no response to light, skin warm abrasion lt (left) face where he fell. Staff A documented in the critical care services provided section "EMS arrived 2005, compressions 2006, Epi given 2012, Atropine 2014, Epi repeat, 2017, compression stopped 2018. Staff A documented in diagnosis section "cardiac arrest-resuscitation halted 2018". Staff A did not document time of death or consultation with the supervising physician prior to removal of life support.

Staff I documented in the emergency room nursing assessment heart rate "asystole". Cardiac strips posted on the record indicated after epinephrine and atropine dosing cardiac electrical activity was present. Staff I documented "2007 cardiac monitor applied - asystole on monitor- 0 (no) B/P (blood pressure) - 0 pulse - 0 respirations - CPR continued and ventilation via ambu bag sustained. 2011- asystole on monitor. 2012- Epinephrine 1 amp given IV- 0(no) response. 2014-Atropine 1 amp given IV - 0 response. 2017 Epinephrine 1 amp given 0 response. 2018 0 BP - 0 spont (spontaneous) resp (respiration) + 0 pulse. 2018 Code called - asystole remains on monitor." All cardiac monitor strips posted on record #4 were in Lead II. Nursing documentation did not indicate the electrical activity of the heart was viewed in any other lead prior to resuscitation efforts being stopped.

Based on review of hospital documents and interviews with hospital staff, the hospital failed to include, analyze and track adverse patient events as part of the quality process to improve patient care and hospital services.

Findings:

1. Review of the Quality Improvement (QI) meeting minutes for 2010-2011, Medical Staff meeting minutes and Governing Body meeting minutes did not demonstrate all adverse patient events were part of the quality improvement program with analysis to improve hospital practices. Four of four records (Pt's 1,2,3,4) documented adverse patient events. There was no documentation in any of the QI or Governing Body Meeting Minutes demonstrating the adverse events had been reviewed, analyzed, or tracked.

2. In an interview on 2/15/11 Staff B told surveyors reviews of the adverse events were done by Staff B, Staff C and Staff D. Staff B told surveyors the adverse events were reviewed with nursing personnel but there had not been any reporting to committees. Staff B told surveyors if the adverse event involved personnel other than nursing, there had not been any other review or review by committees.

3. These findings were reviewed with administration during the exit conference. No further documentation was provided.